Leading and Managing

Part 1 Sarah

The importance of secretaries in health care organisations is poorly understood or recognised.  This month our unit said goodbye to Sarah who has been working with us for the past sixteen years.  Sarah has effectively been the front end of our business.  She received telephone calls from patients and clinicians alike and in a kind, caring and compassionate manner navigated them through an otherwise potentially scary pathway.  Sarah did not have a script nor was she trained to do this; she was a natural.  We looked for a voice for a narrator for our patient information video.  An independent expert identified her voice as quiet yet authoritative and reassuring with a comforting quality.  I noted this many years ago when I had the privilege and pleasure of interviewing Sarah.

Service organisations teach and train people these skills as they understand the importance of the front line and first impressions.  It is true you never get a second chance to make a first impression.  That conversation, what is said and especially how it is said, set the scene for the rest of the pathway.  Sarah pleased all the patients and received outstanding feedback and gifts of chocolate and wine from patients.  People coming to my outpatients wanted to meet the person belonging to the voice.

Sarah coordinated all the information regarding all the patients including the referrals, angiograms, notes and investigations to ensure they were all together in the right place, at the right time to enable me to make the right decisions especially in outpatients.  This removed delays, duplication and uncertainty.  Moreover I had all the information to enable me to make decisions.  Sarah then typed the notes and letters.  She ensured all the relevant people in the patient’s specific pathway received the information regarding the forthcoming treatment and status.

Sarah’s typing was exemplary and accurate in contrast to digital voice recognition systems.  This was further enhanced by her ability to take shorthand (a skill that will soon disappear from use like the slide rule).  Although this was to me a luxury, it was not as important as the collation, correction and presentation of all the information to all the people in the pathway.  This is the inimitable role of a ‘secretary’ and in Sarah’s case it was supplemented with a unique understanding and connection to the operations network of the whole hospital garnered over thirty eight years of service to our hospital.

Concomitantly, Sarah entered every patient’s details on the patient admission administration system and entered basic details on our clinical database for audit.  The time of admission and discharge was collected at the point of contact and confirmed by myself when I entered the clinical data.  This happened on a daily basis.  In essence, we were counting the admissions and defining my finished consultant episodes.  Together we cross checked the discharge summaries and the accuracy of the data that I had entered into the database system.  This was all prospective and real time and has resulted in a very accurate record.

Sarah served two important functions; firstly, Sarah was the meet and greet of our service and secondly, Sarah’s knowledge of the hospital enabled her to expertly navigate through a complex system to ensure the individual patient pathway ran as smoothly as possible.  She received many compliments from other clinicians and junior doctors who always found her extremely helpful in locating details about patients and where they were in the pathway or who to call if there was a problem.  Sarah – thank you very much for sixteen fantastic years – I could not have done half the things I have without your expertise.

David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
Thesis –‘Why can’t Dinosaurs Boogie?’

 

Part 2 – The importance of the ‘Secretary’

The first role of the secretary is a Patient Care Navigator.  The secretary navigates the patient through the clinical pathway keeping them and the clinicians informed at each stage from home to home.  This is critical to ensuring that all the right information is escalated and presented to ensure the right decisions are made at the right time.  Furthermore, the secretary, through telephone conversations with each patient, often understands their individual needs and social circumstances.  The patient’s own priorities often change and are communicated to the secretary.  Their knowledge of individual patients and the nuances of their social support often prove integral to the clinical decision-making and timing of intervention.

In keeping with the principles of service, the character, tone and manner in which the secretary answers telephone enquiries sets the tone for the unit as a whole.  You never get a second chance to make a first impression and whilst most secretaries are good in this aspect of their role, it is not scripted, rehearsed or taught in health care unlike in other service sectors and call centres.

The second role of the secretary is the ‘concierge’ of the unit.  This is a very important role especially at the time of changeover of the junior staff.  They often have a huge knowledge of the workings of the organisation.  The secretary is the part of the mobile Retrieval at Notification Administrator (mRNA) of the organisation.  Using the cellular metaphor, the mRNA connects the nucleus of the cell (the management interior) to all the other organelles (departments) to ensure a smooth coordinated function.  The mRNA of our organisations can be found in the network of secretaries, ward clerks and schedulers in each and every department.  They ensure the information about the patient flows through the system.  mRNA is critical to the survival of the cell and likewise these people are critical to the survival of the hospital.  This essential communication affords flexibility and adaptability.

The third function of the secretary enables the hospital to realise the business of health care.  The secretary ensures that the patient admission and discharge details are correct and therefore the finished consultant episode (FCE) and SPELL in hospital is accurate.  Clinical details are collected at the time of admission and discharge by clinical staff but cross checked by the secretary with the consultant on a daily basis.  This means clinical and operational data is collected as near as possible to point and time of clinical contact with patient thereby maximising the accuracy of the data.  This is essential monitoring of the business, the flow and clinical status of the patient.

Despite all this, mapping of our patient pathway revealed seventeen independent IT systems collecting data about our patients with little or no communication between systems or feedback to the frontline.  The organisation continues to collect data at every level adding layers of duplication with escalating inaccuracies.

The secretaries are the ‘micro’ operational managers of the patient pathways for every consultant team.  They often are sharing the same corridor or space.  Nobody is better positioned to realise accurate clinical and operational data.  Sadly the importance of this is underestimated.  We could have all the data available immediately if we could just link all the secretaries in the organisation and entrust them with this role.

I believe the hospital would run a lot more efficiently if it extended the role of the secretaries and recognised and rewarded their real potential.  Many of the secretaries are doing all this already but I do not think that our healthcare  organisations quite appreciate their valuable contributions at every level.  Typing is no longer the imperative as this can be done by voice recognition systems.  What is essential is accurate clinical and operational data reflecting the time intervals along the pathway and the use of investigations, drugs and consumables.  Patient Level Information and Costing (PLICS), the holy grail of a hospital, will not really be achieved by creating a digital warehouse.  It can, however, be realised bottom up, from the patient-secretary-consultant clinical interface by examining the valuable contribution and extended role of ‘secretary’.

Perhaps we should consign the term ‘secretary’ to history and rename these unsung heroes with an appropriate and modern eponym – they are the mRNA of our complex systems who have the potential to realise the business of health care by navigating the patient through a pathway effectively, efficiently and with a kind, compassionate service focus.  I do not have one name for such a person but I do recognise how valuable they are to my clinical practice.  Join me in saying thank you.

 

David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
Thesis –‘Why can’t Dinosaurs Boogie?’

 

QUIPP (Quality Innovation Productivity and Prevention) was the buzz acronym in 2012. Personally, I was very excited because I felt for the first time in my career in the NHS that doctors and managers alike would put QUALITY before anything else. I thought this would be the first time we would be sharing the same language and singing from the same hymn sheet. Well, that was until I heard our then divisional manager talk about QUIPP as a mechanism for cutting the number of theatres and saving money. I felt that this was putting the cart before the horse. Indeed that may be a conclusion after addressing all the aspects of QUIPP, but QUALITY comes first. That means getting it right first time and every time. The literature is unequivocal; quality drives a reduction in costs.

We are all guilty of jargon. It is widespread in the vernacular of all the professionals in the NHS. FBC (full blood count), U&E’s (urea and electrolytes) and CXR (chest X-ray) roll off the tongues of the clinical staff just as easily as FCE (finished consultant episode), HRG (Healthcare resource groups) and SPELLS (total continuous stay of a patient in a hospital bed) drip from the mouths of the managers. I sat in self learning group on a leadership program and it appeared to me my colleagues revelled in the NHS management dialect and loved to ‘SHMI’ (summary hospital-level mortality index) their way through conversations with these acronyms. Now FCE, HRG and SPELLS are the currency terms for the income generation of a hospital but when I surveyed 173 consultant staff, not one of them could accurately define all the acronyms used by the NHS to realise income and define quality. It strikes me as very strange that the end users and prescribers of health care and technology are totally removed from the decision making and excluded by the language used to define our business. Why can’t clinicians and managers share the same language of quality and waste? It should be very easy to examine the time intervals in the patient pathway and record the consumables. I could look at the top ten drugs spend of the unit and the use of antibiotics does correlate with a cluster of wound infections. The clinical and operational elements of health care do go hand in hand.

I was excited by QUIPP and quality first because I believe that doctors, managers and patients would have no problem defining and agreeing what good quality looks and feels like. Indeed, we are all customers in our everyday lives and we all experience service. There is no hesitation by many walking away from an encounter and complaining, often on social media, but how often do we take time to feedback the good and bad of that encounter – it is not really English? The only way to improve quality in a service encounter is to ask for feedback and act on it! We are in general very poor at this in healthcare. Patients are too grateful and often feel disempowered.
People who are intent on improving their service only score the 5/5 encounters that are defined by an exceptional experience and a highly likely recommendation and return. I was briefly hesitant to ask my own patients in my own satisfaction questionnaires that are handed out by the outpatient clerks – ‘Mr O’Regan treated me with dignity and respect’ and ‘Mr O’Regan listened to my concerns’. I am pleased to record a >95% 5/5 satisfaction but I can tell you it does make you think about your encounter with the patient in each and every clinic. We are there to attend to our patient needs in the best and most efficient manner possible – your own discomfort and distress is of no concern to the patient.

The other altruism of good service is that you never get a second chance to make a first impression. The outcomes of health care are defined by what we say as individuals and do as a team. Many service organisations offer training and scripts to ensure that the first encounter with the customer is good. This is not obvious in the NHS and teams are often not valued for their identity nor are they given discretion to design their own services.

There is another problem. I am disappointed to have to point my finger at the consultants. The vast majority of consultants deliver a high quality, personalised and effective service but that is just it. They have many years of experience but practice an individual art. The science of quality demands that teams adhere to Standards Operating Protocols (SOPs) and they are audited and refreshed according to best evidence and practice. Unfortunately, this is often construed as an affront to well earnt professional autonomy. Institutions like Intermountain Health Care expect everyone adhere to all SOPs but do not necessarily compliance. Clinical acumen can override a SOP but it has to be documented. I have yet to see a scientific approach to QUALITY applied by any team or hospital in the UK. Unfortunately, it really is like herding cats. MY hope and observations lead me to think that this is a generational thing. I enjoy the insight and enthusiasm of the medical students. Perhaps we should teach the science of quality in the undergraduate curriculum.

Lastly, you cannot inspect in QUALITY. Quality assurance more often than not is a process of ticking the box. This does not result is sustainable improvement. QUALITY has to be designed and incorporated into our everyday work. QUALITY improvement and QUALITY science are the tools that are needed.

Good healthcare needs to be SAFE and FLOW with QUALITY
David J. O’Regan
MBA (Distinction) MD BM FRCSEd (C-Th) FFSTEd
Thesis –‘Why can’t Dinosaurs Boogie?’
Network Q – Health Foundation